Pain and Sedation Flashcards
Objectives
- Compare and contrast the different sedatives and analgesics used in the ICU setting with regards to pharmacokinetics, dosing, use and adverse effects.
- Given a patient scenario, design an appropriate analgesic/sedation drug regimen for a patient undergoing mechanical ventilation.
- State risk factors for ICU delirium.
- Recommend appropriate treatment
(pharmacologic and non-pharmacologic) for a patient with ICU delirium.
First-line medication to treat pain in ICU patients- IV route
Opioids
Most common opioids in ICU
Fentanyl, hydromorphone and morphine
Opioid with fastest onset
Fentanyl
All opioids eliminated in
Urine
Only opioid with active metabolite
Morphine
ADE’s of opioids
Hypotension - Morphine Respiratory depression Altered mental status Sedation Constipation, ileus Nausea/vomiting Spasm of sphincter of Oddi – worsened pancreatitis
Ideal sedative
Rapid onset Easy titration Lack of accumulation No active metabolites Rapid awakening Inexpensive
Most remembered event in ICU
Pain
Most common problem in ICU
Anxiety
Consequences of neglecting anxiety
Loss of control of the patient -Ventilator dyssynchrony -Agitation -Increased O2 consumption -Removal of lines/catheters Uncomfortable patient -Anxiety and fear -Lack of sleep -Painful procedures and paralysis (amnestic effects)
Goals of Analgesia & Sedation
Improve patient comfort while using invasive devices (i.e. ventilator) Minimize patient harm -Pulling IV lines -Self extubation -Pulling catheters Decrease anxiety/stress response
Slower onset BZD
Lorazepam
Faster onset BZD
Diazepam
Midazolam
BZD with no active metabolite
Lorazepam
BZD with active metabolites
Diazepam
Midazolam
BZD used in acutely agitated patients
Midazolam
BZD used for long-term sedation (i.e. > 48 hrs of MV)
Lorazepam
BZD used for alcohol withdrawal
Lorazepam
BZD not ideal for acute agitation
Lorazepam
BZD ADE’s
No significant hemodynamic reactions except for midazolam
- Respiratory depression (less than opioids when used alone)
- Propylene glycol toxicity with lorazepam
- Monitor serum osmolality or bicarbonate
BZD that causes accumulation concerns with hepatic and renal failure and with prolonged use
Midazolam
Lorazepam ADE
“Diluent toxicity” Propylene glycol vehicle - Renal failure - Hyperosmolality - Lactic acidosis Risk factors - High-dose, prolonged infusions - Renal or hepatic dysfunction
Propofol ADE’s
Hypotension: dose-dependent
-Urine discoloration (green)
-Hypertriglyeridemia
Increased risk of acute pancreatitis
Discontinue if triglycerides > 400 mg/dL
Monitor serum TG levels: prior to
initiation, every 3-7 days
thereafter, especially if receiving for
>48 hours with doses exceeding
50 mcg/kg/minute
Propofol-related infusion syndrome (PRIS) Associated with doses > 80 mcg/kg/min for ≥ 48hrs
Symptoms include: bradycardia, lactic acidosis, rhabdomyolysis, renal failure
STOP INFUSION IMMEDIATELY
When to use Propofol
Useful for acutely agitated patients & patients requiring sedation with frequent neuro checks
Short-term use preferred
- Less than 72 hrs
Only sedative approved for use in non-intubated ICU patients in the US
Dexmedetomidine
- like clonidine
- central alpha-2 agonist
- Actions NOT mediated through GABA
- Sedative and analgesic properties without producing respiratory depression
Dexmedetomidine ADE’s
Bradycardia Hypertension Hypotension - More common with bolus doses Cardiac arrhythmias
Dexmedetomidine Place in Therapy
Post-surgical sedation with an anticipated short intubation period
Adjunct agent to benzodiazepines
Procedural sedation
Associated with less ICU delirium??
Assessment of Delirium (2 methods)
- Confusion Assessment Method for ICU (CAM- ICU)
- Intensive Care Delirium Screening Checklist (ICDSC)
- Both have good reliability and validity
Most common type of Delirium
ICU delirium is common
Tx of Delirium
NO preferred drug for treating delirium -Orient patient to room and time -Give patients their eyeglasses and hearing aids if needed -Calendars and clocks -Reduce noise and distractions -Place patient in a room with a window
Opioid that causes hypotension
Morphine
DOC for sedation in pt with hypotension and renal failure
lorazepam b/c no active metabolite
Not propofol or dexmedetomide b/c hypotension
